Posture Dependent Hypoxia Following Lobectomy: The Achilles Tendon of the Lung Surgeon?

Background: Platypnoea-Orthodeoxia Syndrome is an uncommon phenomenon characterized by dyspnea/arterial desaturation in the standing position, resolving in recumbency. Some patients present with Platypnoea-Orthodeoxia Syndrome in the early-or-late post-operative period after major lung resection (lobectomy/pneumonectomy). The main cause of Platypnoea-Orthodeoxia Syndrome is an intracardiac anomaly (Patent Foramen Ovalis/Atrial Septal Defect) leading to right-to-left shunt.Objectives: To identify the causes of post-lobectomy Platypnoea-Orthodeoxia Syndrome, and the possible pathophysiologic mechanism.Methods A Pubmed database-EMBASE systematic review was performed in order to find all reports, reporting the occurrence of dyspnea/hypoxemia after lobectomy.Results: 8 studies were found concerning ten patients during the period from 1983-2019.There was 6 male/4 female. The mean age was 62 years. All patients underwent resection of the right lung. The time-interval between the operation and the Platypnoea-Orthodeoxia Syndrome was from 2 days to 3 years. A Patent Foramen Ovalis was present in 90% and in 10% an Atrial Septal Defect was diagnosed. The mean Right Atrial Pressure was 7.5 mmHg, the mean Left Atrial Pressure was 6.6 mmHg and the mean Pulmonary artery pressure was 18.5 mmHg. The mean size of the interatrial communication was 1.62 cm. The inter-atrial communication was closed by open-chest surgical procedure in 3 cases (30%) and in 7 patients (70%) a percutaneous transcatheter device was implanted.Conclusions: Platypnoea-Orthodeoxia Syndrome after lobectomy is a rare cause of post-operative dyspnea/hypoxia. It is the result of right-to-left shunt via an interatrial communication. Mediastinal relocation, stretching of the atrial septum and aortic root dilatation are among the functional elements necessary for the Platypnoea-Orthodeoxia Syndrome manifestation.

Bronchoscopical Repair of Tracheal Laceration Using Conventional Instrumentation: A Novel Technique.

Postintubation tracheobronchial laceration is a rare complication of endotracheal intubation. It requires early serial treatment in cases of pneumomediastinum with difficulty in ventilation to prevent mediastinitis and stricture. The surgical access to the posterior tracheal wall depends on the site of the laceration. A right posterolateral thoracotomy is performed for lacerations of the middle-distal trachea and a transcervical approach for the upper third. Either of them is associated with specific postoperative morbidities. We describe a novel technique of exclusively intraluminal repair of postintubation tracheobronchial laceration using conventional endoscopic instrumentation through a 14.1-mm rigid bronchoscope.

Platypnoea-orthodeoxia syndrome after pulmonary lobectomy: a rare entity with a difficult diagnosis.

Platypnoea-orthodeoxia syndrome (POS) is a rare clinical entity. It is characterized by position-dependent dyspnoea and oxygen desaturation in the upright position with orthodeoxia resolving in the supine position, and is mainly associated with cardiac defects. Only 9 cases of post-lobectomy POS have been reported in the literature. We describe a case of POS in a woman who underwent a lobectomy and in whom POS was diagnosed and treated.

Aortic root replacement and valvuloplasty in a woman with severe pectus excavatum.

We describe a case of a 43-year old woman with Marfan's syndrome, tricuspid valve regurgitation and severe pectus excavatum who required an aortic root replacement and valvuloplasty for an ascending aortic aneurism with aortic valve regurgitation and tricuspid valve regurgitation. There was a severe angulation of the sternum which was close to 1.5 cm to the column vertebrae. Such cases are quite rare and always a challenge for surgeons to achieve adequate exposure of the heart and prevent excessive cardiac compression. We present our access, a safe and efficient exposure of the heart in order to achieve the best outcome.

Pericardial effusion in a young patient with newly diagnosed systemic lupus erythematosus and a mediastinal mass.

We present the case of a 32-year-old-woman who was admitted to the hospital for evaluation of pericardial effusion. The subsequent diagnostic workup revealed the presence of a mediastinal mass along with systemic lupus erythematosus (SLE). The patient underwent thymectomy, and histological evaluation of the resected mass revealed thymic follicular hyperplasia without evidence of malignancy. SLE disease activity was promptly controlled by corticoids. Clinicians should be aware of the occasional association of autoimmune disorders with focal thymic hyperplasia, which might be confused with thymomas or thymocarcinomas.

Prognostic factors in thymic epithelial tumors undergoing complete resection.

BACKGROUND: The prognostic factors in thymic epithelial tumors (TET) are investigated within a 27-year period in 104 patients submitted to surgical and pathologic complete resection of TET with a mean age of 53 +/- 14.6 years and a male to female ratio of 0.73. METHODS: The medical records of all patients were reviewed and six variables that could affect the short-term and long-term survival were entered into a Cox regression model. Follow-up was obtained from medical records and telephone contacts up to September 2004 or until the patient's death. RESULTS: Overall 5-year and 10-year survival was 83% and 78%, respectively. Univariate Cox regression analysis showed that long survival was affected by the age of the patient at the time of operation, the response of myasthenia gravis to the operation, the tumor recurrence, the histologic type according to the World Health Organization (WHO) classification, and the Masaoka stage. Multivariate analysis revealed that recurrence of the tumor (p = 0.001), Masaoka stages II or III (p < 0.001), elder age of the patient at the time of operation (p = 0.045), and presence of the WHO histologic types B2 or B3 (p = 0.05) were bad prognostic factors. CONCLUSIONS: Recurrence of the tumor, the Masaoka staging, the WHO histologic type, and the age of the patient at the time of operation were the most important prognosticators for patients with TET submitted to complete resection of their tumor.

Expression of the RNA-binding protein CRD-BP in brain and non-small cell lung tumors.

The coding region determinant-binding protein (CRD-BP) is an RNA binding protein that recognizes c-myc and IGF-II leader 3 mRNAs as well as the oncofetal H19 RNA. CRD-BP exhibits an oncofetal pattern of expression and has been detected in the majority of colon (81%), breast (58.5%) and sarcoma (73%) tumors. The study of CRD-BP expression was extended in brain tumors and Non small cell lung (NSCL) carcinomas and 12/24 malignant, 2/5 benign neuroepithelial tumors and 4/15 of NSCL carcinomas were found positive. All normal matching tissues tested were found negative. The highest frequency (60%) of CRD-BP positive tumors was observed in meningiomas, either benign (11/18) or atypical (3/3). These findings confirm that CRD-BP expression is restricted in tumors; the frequency of its de novo expression may vary according to tumor type and appears to be an early event in the transformation process.

Basaloid carcinoma, a rare primary lung neoplasm: report of a case and review of the literature.

Basaloid carcinoma of the lung is a rare primary neoplasm, first described in 1992. Basaloid carcinoma is an aggressive subtype of Non small cell lung cancer, with poor 5-year survival, even in stage I and II resected tumors. Differential diagnosis from small cell, Neuroendocrine large cell and poorly differentiated squamous cell carcinoma is difficult to be made. We report a patient with lung basaloid carcinoma, initially diagnosed and treated as small cell carcinoma. Thoracotomy and resection of the tumor following chemotherapy, established the correct diagnosis.